This questionnaire was donated by an intended parent via surrogacy in hopes that it would be helpful to other intended parents and surrogates in their search for the perfect match.
| General Information | Surrogate Physical Description | Education | | First Name: | Height: | High School Grade Point Average: | | State born in: | Weight: | Attended college? | | Age: | | Learning disabilities? | | Race: | | Additional Education information: | | Years Married: | | |
Family Health History
| Relation: Mother | Relation: Father | Relation: Grandmother-Paternal | Relation: Grandfather-Maternal | | Year of Birth: | Year of Birth: | Year of Birth: | Year of Birth: | | Race: | Race: | Race: | Race: | | Ethnic Ancestry: | Ethnic Ancestry: | Ethnic Ancestry: | Ethnic Ancestry: | | Sex and Age of Children: | Sex and Age of Children: | Sex and Age of Children: | Sex and Age of Children: | | Occupation: | Occupation: | Occupation: | Occupation: | | Education: | Education: | Education: | Education: | | Type of personality: | Type of personality: | Type of personality: | Type of personality: | | | | How many siblings do you have? | How many siblings do you have? | | | | Where are you in this birth order? | Where are you in this birth order? |
Personal Profile
• Do you or anyone in your household smoke?
• Have you ever received treatment for drug and/or alcohol abuse? If the answer “yes”, please explain:
• Do you drink alcohol? If it“yes”, when and how often:
• Do you take any non-prescription drugs? If the answer “yes”, please indicate which ones and the reason:
• Are you willing to take health related tests at the expense of the prospective parent(s)?
• Have you had any sexually transmitted diseases? (Hepatitis, herpes, HIV, etc.) If it “yes”, please specify:
• Please list any significant illnesses you have had:
• What was the date of your last check-up with your doctor and its results?
• Please list any prescription drugs you are currently taking and any medical conditions for which you are currently being seen or treated:
• Have you ever been under the care of a psychiatrist? (Hospitalization, medication, on-going therapy?) If the answer “yes”, please explain:
• Have you or anyone in your household ever been arrested and/or convicted of a crime/felony? If it “yes”, please explain:
• Please describe your future goals (personal and career):
• Briefly explain your personal reasons for wanting to be a surrogate:
• Do you want to have any more children?
• What qualities do you consider to be most important in choosing to work with prospective parents?
• As a surrogate, would you have any concerns with the prospective parents participating in the birthing process?
• As a surrogate, what reassurance can you give that you will not change your mind about relinquishing the child?
• How do you feel being a gestational surrogate with affect your life?
• How much contact were you thinking you would like with the parents during pregnancy, delivery and after the child is born?
• What would your response be if the child wanted to meet you?
• Would you like to request any contact with the child after the child is born? If it “yes”, do you wish to receive: (pictures, letters, visits, phone calls ...); how often?
• During a surrogacy process, who can you expect to receive emotional support from:
• How do your parents and friends feel about your becoming a surrogate, if you've told them?
• Is your husband/partner aware of his responsibilities in the medical process and how willing is he to cooperate (such as abstinence, testing)?
• Have you ever been a surrogate or an ovum donor? If it is so, when?
• What are your biggest worries and concerns about becoming a gestational surrogate?
• If your doctor recommended an amniocentesis, would you consent?
• In the event of a major birth defect, would you consider an abortion?
• How many transfer attempts would you feel comfortable with in order to become pregnant?
• If your obstetrician recommended bed rest, would this be a problem for you? What would you consider as adequate compensation for your surrogacy? Please be exact.
• Is there anything you consider important that was not covered in this form?
• How many times have you been pregnant?
• Please list the approximate dates of your pregnancies:
• Please list the age, sex and general health condition of each of your children:
• Were all of your children born healthy? If it no so, please explain:
• Were any of them born at an extremely high or low weight? If it “yes”, please explain:
• Do you have legal and physical custody of all the above children? If don’t have, please explain:
• If you have experienced any complications with any of your pregnancies, please explain the circumstances :
• Which type of birth control are you currently using?
• Did any of your pregnancies take longer than 6 months to conceive?
• Did you need any medical assistance to conceive your children? If it “yes”, please explain:
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